Patients receiving chemotherapy are at risk for thrombocytopenia related to chemotherapy or disease processes. Which actions. are needed for patients who must be placed on bleeding precautions? (Select all that apply)

Use paper tape on fragile skin

Provide mouthwash with alcohol for oral care

Avoid aspirin

Provide a soft bristle toothbrush or oral sponge

Teach to use an electric shaver instead of a razor

Answer and Explanation

Correct Answer : A,C,D,E

A.   Paper tape is gentler on fragile skin compared to standard adhesive tape. It reduces the risk of skin tears and bleeding, making it a safer option for patients with thrombocytopenia.
B.   This option is not advisable. Mouthwash containing alcohol can irritate and dry out the mucous membranes in the mouth, potentially leading to ulcers or bleeding. Instead, an alcohol-free mouthwash should be used for oral care.
C.   Aspirin is an antiplatelet agent that can increase the risk of bleeding. Patients on bleeding precautions should avoid aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) to minimize the risk of excessive bleeding.
D.   A soft-bristle toothbrush or oral sponge is recommended for oral care to minimize trauma to the gums and mucous membranes. This helps reduce the risk of bleeding in patients with low platelet counts.
E.   Using an electric shaver is safer than a traditional razor, as it reduces the risk of cuts and nicks that can lead to bleeding. This precaution is particularly important for patients with thrombocytopenia.

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Correct Answer is C

Explanation

A. Proper wound care is essential in preventing infections, particularly in older adults who may have thinner skin and slower healing processes. However, while this is important, it is just one aspect of a comprehensive infection prevention strategy and does not address broader systemic issues.
B. Older adults are often at higher risk for infections due to waning immunity. Regular vaccinations, such as the flu vaccine, pneumococcal vaccine, and others, can significantly reduce the risk of serious infections. This action is critical but is part of a preventive framework rather than a standalone solution.
C. Hand hygiene is one of the most effective measures to prevent the transmission of infections. Educating clients about proper handwashing techniques and when to wash their hands can significantly reduce the risk of infections, especially in older adults who may be more susceptible due to age-related immune changes.
D. Nutrition plays a vital role in maintaining overall health and supporting the immune system. A well- balanced diet can help older adults fight infections more effectively. However, while important, diet alone may not be as immediately impactful in preventing infections as other measures like hand hygiene and vaccination.

A. Perform a sputum culture B. Instruct the patient to obtain yearly influenza vaccination C. Administer oxygen therapy D. Administer antibiotics

Correct Answer is C

Explanation

A. While obtaining a sputum culture is important for identifying the causative organism and guiding antibiotic therapy, it is not an immediate priority. Delaying this test briefly for critical interventions (like oxygen administration) is acceptable, as stabilizing the patient's oxygen levels is more urgent.
B. Educating the patient about vaccination is important for long-term health and prevention of future respiratory infections. However, it does not address the current situation and does not provide immediate benefit for the acute episode of pneumonia.
C. The patient has a SpO2 of 91%, which indicates hypoxemia (low oxygen levels in the blood). In pneumonia, adequate oxygenation is crucial to prevent further respiratory distress and potential complications. Administering oxygen therapy will help improve the oxygen saturation and support the patient’s respiratory function, making this the highest priority intervention.
D. While antibiotics are essential for treating bacterial pneumonia, they may take time to exert their effects. In this acute scenario, the immediate need is to ensure the patient is adequately oxygenated. After oxygen is administered, antibiotics can be given promptly.

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Patients receiving chemotherapy are at risk for thrombocytopenia related to chemotherapy or disease processes. Which actions. are needed for patients who must be placed on bleeding precautions? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A clinic nurse is working with an older client. What action is most important for preventing infections in this client?

Correct Answer is C

Explanation

A nurse is caring for a client who has pneumonia. Assessment findings include T 100.4 deg F, RR 30, BP 130/76, HR 100, and SpO2 91% on room air. Which of the following is the PRIORITY intervention?

Correct Answer is C

Explanation

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